Safety Notification

This form is to be used to notify the Site Safety Committee of possible hazards on campus and surrounding areas. Examples: inadequate lighting, uneven walkways, icy areas, missing fire extinguishers.

Please fill out the form below to report an incident that has occurred but no personal injury was sustained, or to report an unsafe situation that exists where there is the potential for injury.

This form may also be used for suggesting ways to improve campus safety.

Date:

Time:

Building and Room or Location

Description of Situation (What occurred, When, Where, and Why)

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